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Tuesday, 8 November 2011

Radiofrequency Ablation of Veins and DVT - Answer to You Tube Comment

The following question was posed on You Tube on our video of RFiTT ablation of Varicose Veins (http://www.youtube.com/watch?v=fUQsaY1oY2M). As there is a limit to characters there, we have posted the full answer here:

Question:

What are the chances of developing DVT after closing the GSV with RFA procedure? What would be the best way to avoid developing DVT after RFA on the left GSV? Will there be a chance the the vein can reopen within a few weeks after the treatmenet?

Answer:

Thank you for your question.

If we look at all forms of deep vein thrombosis after all forms of radiofrequency ablation, over the last 12 years, then in our experience the risk is 0.7%, and this is in our published research which you can find via the link: http://www.ncbi.nlm.nih.gov/pubmed/20655773 (the full reference is at the bottom of this comment).

However that is a gross over-estimation compared to our current results under local anaesthetic using the RFiTT device. When we looked at our results in this publication, we were looking at mainly the VNUS Closure catheters, which we do not use more recommend any more, as we find big advantages with RFiTT radiofrequency ablation. For of 17 patients did not have a true DVT but only the minor EHIT. Of the others, the majority of them had other procedures performed including stripping of the small saphenous vein which we do not do any more as these can easily be closed with RFiTT, and also almost all of the DVT is would in patients who had general anaesthetic wear as nowadays we only perform local anaesthetic unless the patient insists.

It is well recognised that general anaesthetic is associated with a higher risk of deep vein thrombosis as the patient does not move so much and also you have to starve before a general anaesthetic, making you dehydrated are more likely to get a DVT. Since using RFiTT for our radiofrequency ablation some two years ago, and since performing all of our procedures under local anaesthetic since 2005, we have not had a major deep-vein thrombosis due to the radiofrequency ablation since. Therefore the risks are very low although of course it is possible that someone somewhere will get one, as people get DVT's occasionally even if they're not having any procedure!

With regards reducing the risks for your left GSV treatment:

- 1 - Have it done under Local Anaesthetic so you are not starved first and mobilising immediately
- 2 - Have sub cutaneous Heparin to cover the procedure (we give one dose during the procedure that lasts 24 hours)
- 3 - Make sure the technique used causes fibrosis of the vein wall - not thrombus formation in a semi-treated vein

Turning to your question about the risk of the vein opening up again a few weeks after treatment, this is virtually impossible provided the correct treatment is performed. When the first RFiTT device was produced, the recommendation was to use a very fast pullback which inadequately treated the vein. Reopening of the vein was very common after this, mainly due to the vein wall being inadequately treated and thrombus being formed inside the vein lumen. We contacted the company and spent some years explaining to them that their recommended treatments were suboptimal but for some while we were ignored. Fortunately Olympus then took over the RFiTT and we worked closely with them to optimise the treatment.

We started using RFiTT when we performed our own research and showed how to reduce the power and to reduce the pullback time. By doing this we make sure that the vein wall is maximally heated and the chance of reopening or thrombus formation is virtually zero.

This research won a prize in an international meeting in Milan a year ago and has been presented in the UK at a major vein meeting. Unfortunately not everybody uses our technique and so having RFiTT or any radiofrequency ablation really depends not only on having the optimal equipment but also ensuring that the person using it is experienced and is using the correct and optimal treatment settings.

We have recently audited our results and have 100% success at closing the GSV at one year.

We have submitted our research to Phlebology journal, but have met many obstacles in getting it published due to the peer review process. We sincerely hope that it will be published soon so that all doctors will be able to use our settings and will be able to give their patients the advantages that we can due to our research.

4 comments:

I was the one who asked the question. Thank you so much for the very well detailed useful information doctor. Many of us would find this information very valuable.(My father just went through vnus closure, 120 degrees celcius, 20 seconds on each segment, general anaesthesia)

Just one more question, I saw the videos I found that usually when the procedure is carried out, the catheter is inserted just under the thigh or below the knee, and reached above until the groin to close off the GSV. What happens to the part of the GSV that extends below the knee area? Since we only close part of the GSV from the Groin to the mid calf, will the entire vein from Groin to Ankle close itself? I believe GSV runs from Groin to the feet? My brother suffers from the same condition and he is thinking of his options. Your reply is very detailed, thanks again.

The procedure that you are talking about for your father is the latest generation of the VNUS Closure - called the VNUS Closure FAST. It is not a true radiofrequency ablation as the radiofrequency current is not transmitted into the vein wall, but is used instead to heat the end 7 cm of the device.

In my clinic, we started using VNUS Closure FAST in 2005 when it first came to the UK, but stopped using it after year or so. There are several reasons we do not use it, but the main one being that the end section is 7 cm long and quite inflexible, meaning that you have to treat any vein in sections of 7 cm.

Although this is acceptable for very simple veins, it is no use whatsoever for a great many complex veins, or a great many recurrent veins which have much smaller segments or segments at a much more tortuous.

Therefore we regard the VNUS Closure FAST as a beginners device, for professionals who are starting their endovenous practice rather than experts who may wish to treat other veins or complex or recurrent patterns.

We would also only ever use any of these devices under local anaesthetic out of choice to keep the risk of deep vein thrombosis, nerve damage, skin burns to a minimum - as well as the risks of general anaesthetic and the costs associated with general anaesthesia and hospital bed.

The question you ask about whether they should be treated from is very interesting.

Although the great saphenous vein starts at the ankle and goes to the groin, it doesn't always need treatment for the whole length. Indeed just this morning I saw a patient who had lost their valves from the groin down to just below the knee, and then the refluxing blood went into a large varicose vein but the bottom part of the great saphenous vein in the lower leg was normal.

Clearly in this case you do not need to treat the lower leg GSV.

In patients who do have reflux all the way from groin to ankle, there is quite a bit of discussion as to where the optimal entry point should be. However to keep nerve damage to a minimum, it is rarely necessary to treat the lower part of the GSV beneath the knee, unless there is a perforator or something else feeding into this isolated segment.

There have been rare occasions when we have had to treat this part of the vein for leg ulcers, but it is very uncommon.

There is a nerve called the saphenous nerve that runs with the vein in the lower part of the leg and the risk of damaging this usually outweighs the benefit of treating the vein right to the ankle.

If you are interested in these different discussions, please keep an eye on the new project I am involved in, www.Collegeofphlebology.com we should have plenty of information when it is launched next year.

Thanks again for the quick and very WELL detailed information, very educative and interesting, every part of it.

We now know what my father went through. I hope the GSV does not open again with this Vnus closure Fast procedure. Exactly as you mentioned, he still has small superficial varicose veins around the back of the thigh and some near the ankle. The doctor decided to go for foam sclerotherapy for these smaller veins, over all my father feels better. The reason Im mentioning this is, I wondered why didnt he use the RF catheter on all veins and now your very detailed response, cleared all of my questions.

I just hope Vnus closure fast really solved his reflux issues and hopefully does not reopen again the future. This was done by a very experienced senior vascular surgeon though.

God I wish I learned medicine (Im 26 and I think its too late) I certainly will be following http://www.collegeofphlebology.com/

We have received an anonymous and inaccurate comment regarding this item on our blog.

Although we are very happy to post controversial comments, and also provide answers to them in order to help educate both patients and professionals into the new advances and research into vein treatments, we will not post such comments if they are anonymous.

It would appear that the comment that we have rejected was written with someone with a clear vested interest in one of the products being discussed.

In such cases, we are very happy to post controversial comments and reply to them, provided they are signed by the author of the comment and we are able to successfully contact that author to verify that it is indeed them who have made such a comment.

We do look forward to active discussions with any such minded people, in order that we are able to increase the general understanding of venous disease and I will research and experience into the optimal treatments that are currently available.